WHO Statement on Caesarean Section Rates Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate Executive summary Since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10% and 15%. Since then, caesarean sections have become increasingly common in both developed and developing countries. When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean sections are associated with short and long term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. In recent years, governments and clinicians have expressed concern about the rise in the numbers of caesarean section births and the potential negative consequences for maternal and infant health. In addition, the international community has increasingly referenced the need to revisit the 1985 recommended rate. Caesarean section rates at the Caesarean section rates hospital level and the need for a at the population level universal classification system WHO conducted two studies: a systematic review of There is currently no internationally accepted available studies that had sought to find the ideal classification system for caesarean section that would caesarean rate within a given country or population, allow meaningful and relevant comparisons of CS rates and a worldwide country-level analysis using the across different facilities, cities or regions. Among the latest available data. Based on this available data, and existing systems used to classify caesarean sections, 1 using internationally accepted methods to assess the 10-group classification (also known as the ‘Robson the evidence with the most appropriate analytical classification’) has in recent years become widely techniques, WHO concludes: used in many countries. In 2014, WHO conducted a systematic review of the experience of users with the 1. Caesarean sections are effective in saving maternal Robson classification to assess the pros and cons of its and infant lives, but only when they are required for adoption, implementation and interpretation, and to medically indicated reasons. identify barriers, facilitators and potential adaptations or 2. At population level, caesarean section rates higher modifications. than 10% are not associated with reductions in maternal and newborn mortality rates. WHO proposes the Robson classification system as a global standard for assessing, monitoring and 3. Caesarean sections can cause significant and comparing caesarean section rates within healthcare sometimes permanent complications, disability or facilities over time, and between facilities. In order death particularly in settings that lack the facilities to assist healthcare facilities in adopting the Robson and/or capacity to properly conduct safe surgery classification, WHO will develop guidelines for its and treat surgical complications. Caesarean sections use, implementation and interpretation, including should ideally only be undertaken when medically standardization of terms and definitions. necessary. 4. Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate. 5. The effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear. More research is needed to understand the health effects of caesarean section on immediate and future outcomes. Introduction For nearly 30 years, the international healthcare a significant expense for overloaded – and often community has considered the ideal rate for weakened – health systems (12, 13, 14). caesarean sections to be between 10% and 15%. This was based on the following statement by a Over the past three decades, as more evidence panel of reproductive health experts at a meeting on the benefits and risks of caesarean section has organized by the World Health Organization (WHO) accumulated, along with significant improvements in 1985 in Fortaleza, Brazil: “[T]here is no justification in clinical obstetric care and in the methodologies for any region to have a rate higher than 10-15%”(1). to assess evidence and issue recommendations, The panel’s conclusion was drawn from a review of health care professionals, scientists, epidemiologists the limited data available at the time, mainly from and policy-makers have increasingly expressed the northern European countries that demonstrated need to revisit the 1985 recommended rate (9, 15). good maternal and perinatal outcomes with that rate However, determining the adequate caesarean of caesarean sections. section rate at the population level – i.e. the minimum rate for medically indicated caesarean Since then caesarean sections have become section, while avoiding medically unnecessary increasingly common in both developed and operations – is a challenging task. To answer this developing countries for a variety of reasons (2, question, WHO conducted two studies: a systematic 3). When medically justified, caesarean section review of available country-level studies that had can effectively prevent maternal and perinatal sought to find this rate, and a worldwide country- mortality and morbidity (4). However, there is no level analysis using the latest available data. The evidence showing the benefits of caesarean delivery process and the results are described in the first part for women or infants who do not require the of this Statement. procedure. As with any surgery, caesarean sections are associated with short and long term risk which At the heart of the challenge in defining the optimal can extend many years beyond the current delivery caesarean section rate at any level is the lack of a and affect the health of the woman, her child, and reliable and internationally accepted classification 2 future pregnancies. These risks are higher in women system to produce standardized data, enabling with limited access to comprehensive obstetric comparisons across populations and providing a care (5, 6, 7). tool to investigate drivers of the upward trend in caesarean section. The proportion of caesarean sections at the population level is a measure of the level of access Among the existing systems used to classify to and use of this intervention. It can serve as a caesarean sections, the 10-group classification (also guideline for policy-makers and governments in known as the ‘Robson classification’) has become assessing progress in maternal and infant health widely used in many countries in recent years (16, 17). and in monitoring emergency obstetric care and Proposed by Dr Michael Robson in 2001 (18), the resource use (8). Over the last few years, governments system stratifies women according to their obstetric and clinicians have expressed concern about the characteristics, thereby allowing a comparison of rise in the numbers of caesarean section births and caesarean section rates with fewer confounding the potential negative consequences for maternal factors. WHO conducted two systematic reviews to and infant health (9, 10, 11, 12). Cost is also a major assess the value, benefits and potential drawbacks factor in improving equitable access to maternal of using this classification to better understand and newborn care, as caesarean sections represent caesarean section rates and trends worldwide. The research process and conclusions are described in detail in the second part of this Statement. 1. Caesarean section rates at the population level Ecologic studies involve comparisons and analysis 1. Based on the WHO systematic review, increases of entire populations, rather than individuals. in caesarean section rates up to 10-15% at the Populations are often defined within geopolitical population level are associated with decreases boundaries, and it is therefore important to in maternal, neonatal and infant mortality differentiate population-based studies from studies (19). Above this level, increasing the rate of of patients in specific health care facilities (‘hospital- caesarean section is no longer associated with based studies’). reduced mortality. However, the association between higher rates of caesarean section and Healthcare facility rates of caesarean births vary lower mortality weakened or even disappeared widely depending on differences in the case mix in studies that controlled for socioeconomic of the obstetric populations they serve, in their factors (3, 21). Since it is likely that socioeconomic capacity and provisions, and in clinical management factors can explain most of the association protocols. Therefore, a population-based between increased caesarean section rates and recommended caesarean section rate cannot be lower mortality in this review, WHO conducted applied as the ideal rate at the hospital level because another study to further analyse this aspect. of these very differences. 2. The WHO worldwide ecologic study found that a In 2014, WHO conducted a systematic review of the substantial part of the crude association between ecologic studies available in the scientific literature, caesarean section rate and mortality appears with the objective